Sample School-Age (Age 5 21) Referral/Request for Referral Letters

Note: Use only one of these samples - Parents referral or CPS Request for Referral

To: New York City Department of Education

Committee on Special Education, District # ___
Attention: CSE Chair

School-Based Support Team, PS/MS ___

Re: Name of Child

Childs DOB

To whom it may concern:

I am the parent of (Name of Child), who is enrolled at _____. I am writing to refer

(Childs first name) for evaluation of eligibility for special education.

IF APPROPRIATE: (Indicate if there is a specific concern. Eg, I am concerned that

(Childs name) may be having particular difficulty with reading. )

I understand that special education is voluntary, and my consent will be required in

writing to perform evaluations to determine whether my child is eligible for services, and
again to begin providing any recommended services.

My mailing address is __________________________ and my daytime telephone

number is ________________.

Thank you for your prompt attention to this referral.

Very truly yours,

________________
KEEP COPY OF LETTER AND FAX CONFIRMATION SHEET IN YOUR FILE

(date of correspondence)

Committee on Special Education

District (Insert district #)
(insert address)
Attention: CSE Chair

School-Based Support Team, PS/MS ___

(insert address)

Re: Childs Name

DOB:

To whom it may concern:

My name is (your name) and I am a Child Protective Specialist at the NYC

Administration for Childrens Services, working with (name of child). I am writing to
request a referral for evaluation of eligibility for special education.

List any/all information that is pertinent to the referral, including any concerns
regarding the childs ability to learn and function in school. Also if you want specific
evaluations completed, you should specify (eg: I am requesting that a speech and
language evaluation be completed as part of the evaluation process).

Please note that _____s parent, __________, will be responsible for the decision of
whether to provide informed consent for evaluation. Her/his address is
_____________________________________.

Should you have any questions or require additional information, I can be reached at
(your contact information). If you cant reach me, you can also contact my supervisor,
(name of supervisor) at (phone number). Thank you in advance for your assistance in this
matter.

Sincerely,

(Your name)
Child Protective Specialist (or other title)

cc: Parent